Health-care Group Holds Strategy Session

September 16, 1988|By Kyle Kulish of The Sentinel Staff

Preferred-provider organizations, the health-care groups that hope to offer patients an alternative to health-maintenance organizations, banded together in Orlando Thursday to promote themselves and present a unified front to the Legislature.

''We anticipate that there will be perhaps a move toward more regulation,'' said Dean A. Dalbery, secretary of the state group. Because PPOs are just beginning to come into their own in Florida, Dalbery said, the group wants to clarify its position before lawmakers consider any action.

HMOs are regulated by state and federal agencies.

But because portions of the PPOs -- insurance companies that offer coverage and the hospitals and physicians that perform the services -- already are regulated, Dalbery said, he is not sure what action the Legislature could take.

The first membership meeting of the Florida Chapter of the American Association of Preferred Provider Organizations attracted about 40 health-care professionals, lawyers and others.

''I think we basically got what we anticipated,'' Dalbery said.

The association rotates its quarterly meetings across the state to reach all potential members, he said. The next gathering is slated for Jacksonville in December.

With HMOs, patients usually have to select a primary physician. They are limited to seeing that physician unless the doctor gives them a referral to see a specialist, Dalbery said.

PPOs allow patients to visit any of its panel providers in the area. For example, the group in Dade, Broward and Palm Beach counties allows patients to choose among 2,200 physicians and 35 hospitals, Dalbery said. Visits to panel providers require a co-payment, generally $5 to $25, Dalbery said.

If a patient preferred to see a provider outside the PPO network, however, he would have to pay charges based on his health insurance coverage -- the policy's deductible payment and 20 percent of the co-insurance payment on the remaining amount. A patient who had a deductible of $200 and received a $500 bill from an outside provider would have to pay the $200 plus $60 for the co- insurance payment.

HMOs typically require a co-payment of about $5 for each office visit but pay 100 percent of the remaining costs, he said.

The majority of PPOs are controlled by large companies and indemnity insurance companies. There are more than 35 PPOs in Florida, said Marge Clauser, director of Healthchoice, an Orlando PPO. She said PPOs first appeared in Central Florida in the early 1980s.